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Medicare Delays Provider ALJ Hearings for 2 Years




by:
Powers Pyles Sutter Verville PC - Washington Office

 
February 13, 2014

Previously published on February 7, 2014

The Office of Medicare Hearings and Appeals (OMHA) recently issued a letter suspending most ALJ appeals for at least 24 months. The administrative appeals process for Medicare claims has been groaning under the number of appeals passing through the system for quite some time. In the past year or so, the Administrative Law Judge (ALJ) level has shown considerable strain, and ALJs have missed deadlines for issuing decisions, with delays of many months for most providers and suppliers. It now appears, however, that the system has completely broken—no new appeals are going to be assigned to ALJs for the next two years or more unless those appeals are filed by a beneficiary.

The appeal regulations allow a provider or supplier to file a request for an ALJ hearing within 60 days of receiving an unfavorable decision from the Qualified Independent Contractor. The Medicare statute requires an ALJ to schedule a hearing and issue a written decision within 90 days after the appeal is filed. According to an undated memorandum issued by OMHA, however, the ALJ appeal process has been put on hold. To date, only those entities with a large number of appeals pending before OMHA have been sent the notification directly, and Powers has obtained a copy. The memo states that OMHA has unilaterally decided to suspend the assignment of new hearing requests. OMHA began deferring assignment as of July 15, 2013. The memo says that OMHA does not expect assignment of ALJs to resume for at least 24 months; the OMHA website currently lists the effective date of the deferral as April 1, 2013 and the wait time as being up to 28 months. Even upon resuming the assignment of ALJs, OMHA expects delays of six months or more for actual hearings to occur post-assignment.

This move by OMHA is unprecedented and seriously concerns providers and suppliers. While many providers and suppliers were already encountering extraordinarily long delays in obtaining ALJ decisions, this institutionalization of the delay is nonetheless quite surprising. Many providers and suppliers are asking how OMHA can so blatantly disregard its statutory mandate and federal regulations. At the same time, providers and suppliers are asking what can be done about the situation.

OMHA is holding an information meeting about this delay on Wednesday, February 12, 2014.

 

The views expressed in this document are solely the views of the author and not Martindale-Hubbell. This document is intended for informational purposes only and is not legal advice or a substitute for consultation with a licensed legal professional in a particular case or circumstance.
 

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